How Do I Get Onto a Medical Provider Network?

Saturday, May 8, 2004 | 0

The following question and answer series appeared recently in the Medical section of the WorkCompCentral Professional Forums - a physician fairly new to the workers' compensation system wants to become a part of a medical provider network. The answers are interesting and relevant to practitioners of occupational and industrial medicine in California:

Question:I am interested in finding out how one gets onto a Medical Provider Network?

I've been in practice for about 2 years now, treated 2 W/C patients (one referred by an orthopedist, the other referred by an attorney). I believe all the services I have rendered have been quite reasonable (I have the documentation to substantiate it). I'm neither defense nor applicant oriented (since I have been around for only 2 years).

From someone in the defense side of it, how can I get on these provider networks ? Is it only going to consist of those Doctors which have a record of defense work or is any 'new blood' going to be allowed ?

Also, who (in the insurance companies) do I speak to? Adjusters? Medical Liasion officer? etc. I know these laws are recent and there is more speculation than solid info. Would appreciate any help. Thanks.

Answer 1:I suspect that most of the networks are for all practical purposes already in existence. Carriers currently contract with various organizations for discounted rates and various other issues. Those organizations will simply be reformatted into medical provider networks with relatively little thought given to applicant v defense issues. Accessibility, size of networks, access to hospitals and other economic factors will predominate over orientation.

Most major health carriers already have such networks available and they are going to be where the action is.

Answer 2:I know the carrier I work for already has such a network in place for our HCO accounts. We use this same network while we retain medical control on non-HCO files, and whenever an Injured Worker (IW) needs a referral, we go to the same network for our first choices.

Most of these doctors are Moderate to Conservative. I don't know if any of them are "Hacks", but of course we have had the problem of the occasional Doc-In-The-Box (DITB)who P&S'd an IW a little too soon, leading to litigation.

I actually try to refer care from the DITB providers as soon as possible, and get them into a good treater who will give me good reports and make sure the IW gets they care they need, without running the tab worse than Homer Simpson at Mel's. Most of DITB's, I've noticed for whatever reason, are unable to handle many claims, when they go beyond the Medical Only phase of care.

What I see happening is the applicant attorneys will request change of Primary Treating Physician (PTP). I send them 5 docs, they will reject them and keep requesting until they HAPPEN to come up with someone who they like. What I hope will happen is we will publish our network, say online, and a PTP, IW, or A/A can go online and pick a treater they like in the area. After all, as long as the treater is in network, we pretty much have to authorize it.

The one aspect I haven't seen yet is the deadline for supplying a doctor. Currently, I have 5-7 days, depending on which part of the LC I look at. I am assuming then if I fail to supply them in a week with a list of docs, they can go anywhere at that point, just like now, and that at that time I lose medical control of the claim. Those are the issues I am interested in on this.

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